Description of the Study Setting
The study was carried out in the Mtwara Rural District in south-east region of Tanzania from June 2004 to November 2006. Mtwara is one of the least developed regions in country and the majority of its population are poor subsistence farmers earning below 1 US$ per day and hence living under the poverty line. The dominant ethnic group is Makonde. Others are Yao and Makua. 95% of the populations are Muslim. About 40% of the population do not have primary education . In 2005, maternal mortality ratio in the district was estimated at 600 per 100,000 live births and infant mortality is high at 136 per 1000 live births. Mtwara Regional Hospital serves as the first referral level for obstetric emergencies for six districts in the region including Mtwara rural district . In 2006, only 36% of deliveries occur in health institutions .
The Study Site and Population
The study took place in four villages Mahurunga, Kitunguli, Kihimika and Tangazo, with a total population of 8300. All deliveries which occurred between October 2004 and November 2006 (N = 512) were included in the study. The four villages are located in Mahurunga Ward in Kitaya Division. The area is served by one health centre and a dispensary which both provided maternal and child health services including delivery care. The two facilities were staffed by two clinical officers and three skilled midwives. According to the Tanzania health system, these lower level health facilities provide only normal delivery care. In Tanzania, midwives, staff nurses and public health nurses with midwifery skills and mother and child health aide (MCHA) are allowed to perform normal deliveries. Thus, women with risk factors and those who develop obstetric complication are to be referred to Mtwara Regional Hospital, which is 50 km away and the closest place providing comprehensive emergency obstetric care services.
Besides general public awareness education through media, no community-based interventions have previously been carried out in the study area to promote utilization of skilled attendants at delivery.
The study design and a brief description of intervention
The study was designed as a community-based intervention study, using a pre-post comparison of the same group; which was implemented in three phases: situational analysis June 2004; intervention October 2004 to October 2006 and the post-intervention assessment in November 2006. The intervention package comprised of two main components (a) training of Safe Motherhood Promoters (these were trained specifically for this intervention study) and (b) education and awareness on maternal health aspects. As specified in more detail below, the study comprised a quantitative approach with respect to the pre-defined primary and secondary study outcomes. Responses to selected open-ended questions were also analyzed qualitatively.
Community entry and baseline survey
After consultation with the village governments, several meetings were held in each of the four villages. The initial meeting aimed at informing community leaders and other stakeholders and discussing the objectives and the implementation plan with them. After reaching a consensus, the baseline survey was carried out between June and July 2004. This survey exercise was used as initial stage of community entry and relationship building and to prepare the community for the intervention. After the situational analysis exercise, preliminary results and the intervention package were presented and discussed in a second community meeting which involved village government and political leaders, religious and opinion leaders, village health workers, school teachers, health providers Traditional Birth Attendants (TBAs) and traditional healers. Their inputs and recommendations were incorporated in the final intervention package after being reviewed by district health team. This consultation process was continued with further village meetings throughout the study.
The key elements of the intervention were:
Training of safe motherhood promoters, using participatory adult learning methods.
To conduct home visits, to educate pregnant women and their husbands and key community members about danger signs and pregnancy complications.
Home visits to pregnant mothers to inform on early and complete ANC visits and the importance of a birth preparedness plan
Follow-up of pregnant mothers to encourage delivery with a skilled attendant and data recording.
Raising awareness on maternal health issues through community meetings and video show
Criteria for the selection of SMPs were established in public meetings and included (1) she/he must be a married person, (2) able to read write, (3) accepted by community, and able to educate others. However, four TBAs and two community representatives who did not know how read and write were selected due to their popularity and acceptance in the community. A total of 50 SMPs (28 females and 22 males) were selected with an average of 10-12 SMPs per village (3-5 from each sub-village). SMPs varied in age from their mid-twenties to late early sixties. The age range was 23-64 years, while the median age was 37 years old. SMPs were drawn from community groups including village government, religious institutions, opinion leaders, community health workers (CHWs), traditional birth attendants (TBA), and village health committees. These SMP's were trained in their villages for 12 days, using a participatory adult learning methods [27, 28]. The topics covered conception and pregnancy, complications and danger signs, risk behaviour, birth preparedness, rationale and content of antenatal care as well as the importance of skilled delivery care. The key messages were derived from the Tanzanian National Reproductive Health and Communication Strategy and Safe Motherhood Initiatives Messages .
A post training feedback meeting with community leaders and SMPs was held to develop a plan of action on how to implement the intervention activities. The tasks of SMPs that were agreed upon included:
To conduct home visits, to educate pregnant women and their husbands and community key members about danger signs, delivery complication and prevention of HIV/AIDS transmission from mother to child.
To motivate women and their families to book early for ANC and to have birth plans.
To promote and facilitate women to deliver with skilled attendants.
To conduct monthly meetings and data recording.
Other post-training activities by SMPs were community awareness activities through educational meetings, supported by video shows and other media outlets.
Organizational and implementation structure
Experienced local health officers who participated in the baseline and the training of SMPs coordinated the intervention activities which were also integrated within the existing primary health care (PHC) activities. Each SMP were assigned a maximum of 12 households to care for including data collection and reporting on a monthly basis. The SMP team worked under the Village Health Committee.
Follow-up and monitoring activities
Four experienced research assistants in community health were recruited and trained on data collection and ethical issues. All the study tools were translated into Kiswahili and piloted. Necessary changes ware made accordingly. The main researcher conducted field visits and supportive supervision to both SMPs and local coordinators. Problems identified and lessons learned were discussed in a joint meeting with the SMPs, village leaders and the Mother and Child Health (MCH) team.
Quantitative data on place of delivery, delivery attendant and use of antenatal care services
Data on all deliveries (N = 512) in the 4 villages were collected by SMPs during home visits, supported and supervised by the research assistants and the study coordinator, for a period of three years (October 2004- to November 2006). The data included information on maternal age and parity, the attendance at ANC clinics, risk factors as identified by the health providers, referral status, place of delivery and the person assisting during delivery. These data sets were crosschecked with health facility records from the study villages, which recorded 459 deliveries (including home deliveries by asking women and through TBAs records) during the study period; fifty-three deliveries less than the number reported by SMP. All of these 53 additional deliveries were followed up and confirmed by the research assistants. Thus, data collected by SMPs were more complete because they lived in the community and each SMP had no more than 12 pregnant women to follow-up per year.
Quantitative and qualitative data on safe motherhood knowledge and perception of the intervention
These data were derived from interviewing a random sample of residents of the four villages including female (pregnant, nursing mothers, and mothers) as well as male (husbands of the same) aged 18 years or above. The composition of all households was established in the baseline survey. From this list we randomly selected 238 respondents prior to the intervention and 242 in post-intervention to participate in semi-structure individual interviews (SSIs). SSIs were conducted by the main researcher and two trained research assistants.
The SSI tool consisted of closed and open-ended questions. We collected information on demographic characteristics and on knowledge on referral issues such as risk factors, danger signs, barriers for referrals, and choice of place of delivery in case of non-compliance. We also asked questions on the weaknesses, strengths and the general perceived benefit of the intervention. The interview data were analyzed quantitatively. In addition, responses to open-ended questions on perceptions were analyzed qualitatively with key statements being presented in the results.
In the final assessment in 2006, the 242 respondents included 153 mothers and 69 husbands of those women, as well as 20 women who were pregnant during the finals assessment. The age range for respondents was between 19 and 53 years while the median age was 29 years.
After data collection, a one day community feedback meeting which involved sixty community leaders (23 females and 37 males) from all villages was held. The feedback meetings involved a ward executive officer, village leaders, religious and political leaders, SMPs, school teacher and health providers. A brief report about preliminary findings was presented and main issues emerged from our findings were discussed in four village-based groups and in a large group. The discussion also helped to clarify some of the issues raised during interviews and was used to validate these findings.
Data from the 512 delivery records, 238 individual interviews (SSI) at pre-intervention and the 242 SSIs at post intervention were entered into a computer program using EpiInfo 6 data entry program. Data cleaning and analysis was done using the same programme. In addition to the primary study outcome which was the coverage of skilled delivery attendance, we also analyzed secondary outcomes which were ANC attendance and knowledge on Safe Motherhood issues. We also performed a process evaluation through assessing the acceptability and appreciation of the SMPs, the coverage of home visits, and the drop-out rates of SMPs.
This study was part of a larger study on maternal and perinatal health in Mtwara Region. Ethical approval was granted by the Muhimbili University of Health and Allied Sciences Ethical Committee. Official permission was obtained from the Mtwara Regional Executive Officer, the Mtwara Rural District Administrative Officer, the Mahurunga Ward Executive Officer and all village chairpersons from the study area. Before the interview participant were assured of confidentiality and the written consent was obtained. As part of the ethical obligations preliminary findings were presented and discussed in the community feedback meetings which involved all sub-village and village leaders, religious and opinion leaders, health providers and the safe motherhood promoters.